Diabetes is Primary 2014 Part 3 - A Diabetes Core Update Special Edition: Insulin Management

Summary

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Podcast Summary: Diabetes Core Update

Special Edition: Diabetes is Primary 2014 Part 3 – Insulin Management

Date: August 7, 2014
Host(s): Dr. Neil Skolnik, Dr. John J. Russell
Guest: Dr. Eric Johnson, University of North Dakota School of Medicine

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Episode Overview

This special edition of Diabetes Core Update focuses on insulin management in type 2 diabetes, featuring highlights from Dr. Eric Johnson’s ADA Scientific Sessions presentation. The episode offers practical, up-to-date clinical guidance on initiating and optimizing insulin therapy for adults with type 2 diabetes, barriers encountered in practice, myths about insulin, and effective strategies to maximize patient acceptance and safety.

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Key Discussion Points & Insights

1. When to Initiate Insulin in Type 2 Diabetes

• Dr. Johnson emphasizes that nearly all people with type 2 diabetes will eventually need insulin due to progressive beta-cell decline ([01:29]).

• Insulin should be considered when A1C is above target (generally >8–8.5%) or after about five years of diabetes duration as endogenous insulin production wanes.

• Certain clinical scenarios (e.g., significant hyperglycemia, renal impairment, cost concerns) may prompt earlier use.

  “If they live long enough, all of them are going to need an insulin product at some point... quite often our consideration comes when the person's A1C is elevated, quite often when they get beyond eight or eight and a half or not meeting their appropriate target.”
  — Dr. Eric Johnson [01:29]

2. Positioning Insulin in Treatment Algorithms

• The ADA and AACE algorithms both recognize insulin as a valid second-line (after metformin) or subsequent agent.

• In severe hyperglycemia, insulin can be first-line ([02:06]).

  “Shows insulin as possibly a second line agent in some persons with type 2 diabetes and certainly can be considered for a third or fourth line treatment as well.”
  — Dr. Eric Johnson [02:06]

3. Choosing Insulin as Second-Line Therapy

• Insulin preferred when:

  • A1C is significantly above target
  • Oral/injectable options are limited due to renal disease
  • Cost is a concern (basal insulins often less expensive) ([02:50])

  “Basal insulin may be the most cost-effective approach, but it's certainly a good potent choice for some persons as a second-line agent.”
  — Dr. Eric Johnson [02:50]

4. Adjusting Other Medications when Starting Insulin

• Dose reductions in sulfonylureas may be needed to reduce hypoglycemia risk.

• Consider adjusting thiazolidinedione (TZD) doses to avoid weight gain or edema.

• Non-insulin injectables (GLP-1s) may also warrant dose changes ([03:40]).

  “Particularly in the case of sulfonyureas, we may want to decrease the dose…to limit the possibility of hypoglycemia...”
  — Dr. Eric Johnson [03:40]

5. Initial Insulin Strategies & Titration

• Focus on patient confidence and comfort with modern insulins, especially pen devices.

• Start with 10 units of basal insulin daily, titrate by 3 units every 3–5 days; goal fasting blood sugar individualized (e.g., <110–140) ([04:27]).

• Alternatively, a weight-based dose can be used, but simplicity often key.

  “Quite often you can start at 10 units daily with a basal insulin and then increase that, perhaps three units every three to five days...”
  — Dr. Eric Johnson [04:27]

6. Patient & Provider Barriers to Insulin Initiation

• Emotional barriers from past negative perceptions; providers should confidently communicate advantages of modern insulin and ease of pens ([06:04]).

• Historic linkage of insulin initiation with complications (e.g., amputations) is a misconception stemming from delayed therapy in the past ([06:52]).

  “I have patients who will tell me I had an older relative...on an insulin product 15 or 20 years ago. They didn’t do well with it. So I want to contrast that with a more modern product...”
  — Dr. Eric Johnson [06:04]

7. Common Pitfalls in Insulin Management

• Failure to provide clear titration schedules results in inertia ([07:33]).

• Need for frequent patient follow-up or written algorithms.

• Splitting basal insulin unnecessarily in most cases—better alternatives exist (additional mealtime insulin or GLP-1 agonists) ([07:33], [08:43]).

  “Person will be started on 10 units or some weight based dose and then nothing happens until the next appointment...I think most patients, if we give them written directions for a titration algorithm, they're going to be able to handle that...”
  — Dr. Eric Johnson [07:33]

8. Optimizing Dual Therapy or Stepwise Intensification

• For escalating doses of basal insulin, instead of splitting doses, add GLP-1 or a bolus of rapid-acting insulin before the largest meal ([08:43]).

• Postprandial glucose becomes a bigger contributor to elevated A1C as patients approach target values ([09:16]).

  “If I get to the maximum dose of a pen...maybe it's time for me to be thinking about adding mealtime insulin...”
  — Dr. Eric Johnson [11:07]

9. Educating on Glucose Monitoring

• Don’t over-burden patients; recommend strategic, variable self-monitoring (e.g., rotate times of checks, include postprandial readings if on mealtime insulin) ([09:41]).

• “More data, less pain” approach for actionable results.

  “Maybe rotate those around, not just be focused on morning and evening. Maybe try to do some in the middle of the day or maybe two hours after a large meal...”
  — Dr. Eric Johnson [09:41]

10. Preventing Hypoglycemia and Quality of Life Considerations

• Avoid “over-basalizing”—if high doses of basal insulin needed, consider adding GLP-1 or mealtime insulin.

• Be mindful of hypoglycemia risks; tailored regimens for individual quality of life ([11:07]).

  “If we don't over basalinize our patients, we're less likely to have issues with hypoglycemia...”
  — Dr. Eric Johnson [11:07]

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Memorable Quotes

• On patient perceptions:
  “We need to be pretty matter of fact about this. We need to talk about how modern insulin products are much safer.”
  — Dr. Eric Johnson [06:04]

• On titration and patient empowerment:
  “…it gives [patients] a lot of control to incrementally get toward their goal.”
  — Dr. John J. Russell [05:36]

• On addressing misconceptions:
  “That’s often because people have waited too long until they start more aggressive management.”
  — Dr. John J. Russell [06:52]

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Timestamps for Key Segments

• Introduction & Guest Welcome: [00:11–01:17]
• When to Consider Insulin: [01:29–01:58]
• Insulin in Treatment Algorithms: [02:06–02:45]
• Insulin as Second-Line Therapy: [02:50–03:28]
• Adjusting Other Agents: [03:40–04:17]
• Starting & Titrating Insulin: [04:27–05:36]
• Barriers to Initiation: [06:04–06:52]
• Pitfalls in Insulin Management: [07:33–08:38]
• Alternative Intensification Strategies: [08:43–09:16]
• Glucose Monitoring Advice: [09:41–10:36]
• Hypoglycemia, Quality of Life, and Over-Basalization: [11:07–11:58]
• Conclusion: [12:17–12:20]

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Summary Tone & Clinical Relevance

The episode maintains a practical, reassuring, and evidence-focused tone, emphasizing patient empowerment, simple protocols, and the importance of dispelling outdated fears about insulin. Effective insulin management requires both clear provider guidance and individualized patient education—core messages of both Dr. Johnson and the hosts.

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For more primary care diabetes guidance and evidence reviews, visit:
www.diabetesjournals.org

Transcript

[A]

Hello, I'm Dr. Neil Skolnick and I'd like to welcome you to a special edition of Diabetes Core Update. On this special series of podcasts, we will be interviewing faculty who presented during the American Diabetes Association Scientific Sessions Diabetes primary conference on June 14, 2014. On today's podcast, we will be hearing highlights of a Talk given by Dr. Eric Johnson on managing insulin therapy.

[B]

Eric Johnson is an Associate professor in the Department of Family and Community Medicine and Director of Interprofessional Education at the University of North Dakota School of Medicine and Health Sciences in gran for North Dakota. Dr. Johnson also serves as Assistant Medical Director of the Diabetes center at Altru Health System and Assistant Medical Director of Valley Memorial Homes, also in grand forks. Welcome, Dr. Johnson.

[C]

Thank you, Dr. Skolnick. Great to be here today.

[B]

Why don't we start with when would you consider insulin in a person with type 2 diabetes?

[C]

Persons with type 2 diabetes, if they live long enough, all of them are going to need an insulin product at some point. Quite often our consideration comes when the person's A1C is elevated quite often when they get beyond eight or eight and a half for not meeting their appropriate target, and also in patients who've had diabetes maybe five years or longer, as they probably have significant beta cell decline by that point in time.

[B]

Okay, and then how does that fit in with the current algorithms for treatment of hyperglycemia?

[C]

Sure. The newest American Diabetes association algorithm, the Managing Hyperglycemia document that came out in 2012, shows insulin as possibly a second line agent in some persons with type 2 diabetes and certainly can be considered for a third or fourth line treatment as well. As far as the American association of Clinical Endocrinology algorithm, they have similar guidance that this can be a second line agent commonly or beyond, but sometimes might be a more first line agent for those with very elevated blood sugars or A1Cs.

[B]

When would you use it as a second line agent after Metformin?

[C]

I think that I would do that if I saw a person that had blood sugars that were well out of control. Those with an A1C who we would want to target at less than 7 and their A1C is well over 8. Or in some patients who maybe have renal disease, which limits a lot of other options with other injectables or oral agents. Sometimes we want to consider that too as a cost factor as basal insulin may be the most cost effective approach, but it's certainly a good potent choice for some persons as a second line agent.

[B]

Excellent. And then when you start insulin what sort of adjustment should we think about with other oral agents that a patient may be on?

[C]

Particularly in the case of sulfonyureas, we may want to decrease the dose of the sulfonylurea so as to limit the possibility of hypoglycemia, particularly as we appropriately titrate basal insulin as well, somebody who's on a tzd, we may want to consider a dosage adjustment there to limit weight gain or edema that might happen when we start an insulin product. Other injectables that are non insulin, such as GLP1s, those might also need a dosage adjustment if insulin is added.

[B]

Okay, that's helpful. And then when we're starting insulin, what are some strategies for how to start insulin in patients with type 2 diabetes?

[C]

I think a lot of it is to build some confidence with our patients. Right away with this, I talk about the safety of modern insulin products, their ease of use, particularly with 10 devices, which have really changed the way that we instruct persons with type 2 diabetes on insulin use. Quite often I will tell them that this is an injection that's different than their experience would be with like a vaccination or a blood draw. And we show them that these are very small, narrow gauge needles and are very comfortable. When we're thinking about the titration schedule, quite often you can start at 10 units daily with a basal insulin and then increase that. Perhaps three units every three to five days would be one strategy until the fasting blood sugar is an appropriate target for that patient. Say maybe less than 110 to 140 depending on the person. You can also do a weight based dose approach, but I think more often than not we do the 10 units daily and go from there.

[B]

That makes sense. In my practice that approach has been wonderful because it allows me and the patient to feel comfortable that we're not going to suddenly make them hypoglycemic. And then it gives them a lot of control to incrementally get toward their goal. What are some of the barriers you mentioned, concerns about needles as one that we'll see with starting insulin?

[C]

I think some barriers are with providers. I think we don't always sound confident, like this is a good choice for a person who particularly this might be a second line agent. I think we need to be pretty matter of fact about this. We need to talk about how modern insulin products are much safer. I have patients who will tell me I had an older relative or family member or friend who was on an insulin product 15 or 20 years ago. They didn't do well with it. So I want to contrast that with a more modern product like we would use today. I also really focus on the fact that many of these insulins come in pens, so a good number of patients are not going to need to use bottles and syringes, which can be quite cumbersome and difficult for many patients.

[B]

That's a great point. I've also heard, we've all heard misconceptions that patients have that they had a relative who started insulin and then needed an amput, equating the starting of insulin with complications. And of course nothing could be further from the truth. That's often because people have waited too long until they start more aggressive management.

[C]

Particularly in the past that would have been true and we would have seen that more likely 15 or 20 years ago. Just waited too long to get them under better control.

[B]

What are some of the pitfalls that people make with regard to insulin management?

[C]

I think from a provider point of view, we sometimes forget to come up with an appropriate titration schedule. Person will be started on 10 units or some weight based dose and then nothing happens until the next appointment. I think most patients, if we give them written directions for a titration algorithm, they're going to be able to handle that or we should do some kind of phone follow up with them to help them do those titration schedules. I think some other things I see too is quite often a basal insulin will get split into two doses and I'm not sure when or why that happens in a lot of practices, but I don't often do that. If I'm going to put a patient on a two shot program, I'm quite often thinking of something else besides splitting the basil in half. Now we all have patients that are on very large doses of insulin and they're going to have to have two different injections of basil just because it's a large dose. But for many patients I don't do that. I think about doing something else.

[B]

And what would that something else be that you're thinking about?

[C]

Quite often I will think about adding a GLP one if they're not already on it. Or I might add a bolus with the largest meal of the day of a rapid acting insulin. And I talk to patients about how this is a better two shot program for them. We may get some better control of their postprandial blood sugars at least part of the day if we do that and treating post meal blood sugars as well as treating fasting blood sugars. Is pretty important for most patients when we're trying to reach target that's appropriate for that patient.

[B]

That's a great point that as patients get closer and closer to that target, A1C, perhaps of 7%, a greater proportion of the excursion is due to postprandial sugars rather than just fasting blood sugars. How do you counsel patients with regard to finger stick glucose testing and insulin use?

[C]

When we start somebody on an insulin product, if the person has not been doing a lot of testing, we talk about ways to make their testing more effective without making it sound like they have to do lots and lots of finger sticks. When an insulin product is started. For most type 2s, if they're on agents that do not have high risk for hypoglycemia, like, say, metformin, I'd like them to do one or two a day, but maybe rotate those around, not just be focused on morning and evening. Maybe try to do some in the middle of the day or maybe two hours after a large meal. And we can get a lot of information that day, but still limit it to a couple of finger sticks a day. If we add mealtime insulin to the largest meal of the day, I'd really like them to focus on the two hours after that meal because that really helps us gauge how effective the addition of that bolus is.

[B]

Those are great points, and particularly, I think, worth emphasizing that idea that you can vary the times of day when you're checking blood sugar so that patients don't have to be checking four times a day necessarily to get the information that you need over time. And then lastly, how do you see the balance between good blood glucose control and high hypoglycemia when using insulin in patients with type 2 diabetes?

[C]

I think some of it is not getting to giant doses of basal insulin unnecessarily. If I get to the maximum dose of a pen, say 60 or 80 units, maybe it's time for me to be thinking about adding mealtime insulin with the largest meal of the day or adding a GLP one if they're not already on that. I think if we don't over basalinize our patients, we're less likely to have issues with hypoglycemia. And of course, as you know, that's been a big push with the ADA the last few years is to pay attention to hypoglycemia and quality of life. I think if we're a little smarter with our programs with respect to insulin, instead of just pounding them with basal insulin, that can really help us with that. And it does give us some focus on post meal blood sugars as well as fasting.

[B]

That's great. And then as we're getting to those higher doses of basal insulin, then thinking, as you said, of starting mealtime insulin, particularly before the largest meal of the day. Well, Eric, this was really helpful. Thanks so much for taking the time to talk to our listeners.

[C]

Yeah, much appreciated. Thank you.

[A]

This concludes this special edition of Diabetes Core Update on the next installment from the Diabetes primary meeting this past June. At the scientific sessions, we will hear Martha Funnell discussing motivational skills in the management of diabetes and Dr. Charles Schaefer discussing managing diabetes on a budget.